President Ramaphosa, it’s time to turn a disease system back into a health system

6 Jun 2018

There are hundreds of things going wrong in the health system. Mini Life Esidimenis occur every day. But as with a cancer, the more pervasive the crisis becomes, the bleaker the prognosis. As we can see in many of our SADC neighbours, as well as in BRICS partners such as India, the death of a public healthcare system is not an impossibility. It is the inevitable end result of neglect.

Dear President Ramaphosa,

Thank you for what you are doing to try to restore good governance to our country and root out corruption. I am sorry to have to add more challenges to your to-do list.

In case you missed it last week the SA Committee of Medical Deans issued a statement that called on the government to take drastic steps to address the ongoing health crisis in the country. You may have missed it because the word “crisis” is over-used. But I’m afraid that we have to admit that our public health system is facing an acute crisis which, if it doesn’t get the highest level of leadership, may cause its death.

There are hundreds of things going wrong in the health system. Mini-Life Esidimenis occur every day. But as with a cancer, the more pervasive the crisis becomes, the bleaker the prognosis. As we can see in many of our SADC neighbours, as well as in BRICS partners such as India, the death of a public healthcare system is not an impossibility. It is the inevitable end result of neglect.

Invest in the right to health

In 2001 a report by the World Health Organisation Commission on Macro Economics and Health provided evidence of a direct connection between the state of health of a population and its economic productivity. It showed the correlation between investment in health and economic outcomes: the better the health, the better the productivity. That was then. This is now. Nothing has changed.

So, President Ramaphosa, as you work to rebuild and reignite our economy, and fix the State-owned Entities (SoEs), that fact alone should be an incentive to fix the health system.

Health is hope.

Health is energy.

Health is an investment in dignity.

But having “access to healthcare services” is also everyone’s constitutional right – a right on which your government was found to be “delinquent” – a word used by Justice Dikgang Moseneke as he summed up the horror of the Life Esidimeni tragedy.

President Ramaphosa, the crisis in the health system is much more serious than you admitted in your State of the Nation Address.

Many parts of the health system have become disease systems. As Minister Aaron Motsoaledi often points out, we spend huge resources treating (or in many instances not treating) diseases that proper planning and implementation should be able to prevent. For example:

Lack of hygiene and infection control means our clinics often become the source for onward transmission of infectious disease, particularly tuberculosis.

It’s estimated that preventable mental illnesses alone cost our country up to R40-billion per annum.

We kill and maim far too many newborns, because of shortages of staff, equipment and medicines – and then we pay out of our nose in medico-legal claims, now totalling an estimated R51-billion in contingent liabilities facing provincial health departments.

It often seems that in health we wait for a preventable crisis to occur, then we pay for it. This is a foolish and unsustainable way to manage a health system.

On 15 May 2018, Minister Motsoaledi outlined his vision for the year ahead in his budget speech. The speech was in places honest and ambitious but in others it avoided frank admission of the scale of the crisis we face. I often pity Minister Motsoaledi for the number of fires he is called to put out on a daily basis. But one of the worst consequences of this is that the minister must constantly be reacting to crises rather than getting ahead of the curve.

So, President Ramaphosa, please do not read this letter as an attempt to berate or embarrass you. It is trying to give voice to desperate health professionals and patients who approach SECTION27 daily with their horror stories. It is an appeal for your Presidency to publicly give the same priority to fixing the health system as it does to eliminating corruption. And, in making this appeal, I now make a few humble suggestions about how political leadership by you on health might make a difference.

Please order Premiers and ANC MECs of Health to follow Minister Motsoaledi’s leadership and priorities, especially where those plans are reasonable and evidence-based.

President Ramaphosa, please try to get your own house in order. Factionalism plagues health as much as it does South African Airways or Eskom. Often, ANC politicians appear to have no discipline or respect for their own leadership.

Let me give you an example. In his budget speech the minister announced plans to “decant 50,000 patients to 250 private General Practitioners (GPs) for antiretroviral (ARV) treatment between October 2018 and December 2020, and build up from there.”

He added:

“The State will supply the ARVs and pay for the laboratories. The GPs will be paid their service fees.”

Yet in Limpopo the MEC for Health, Dr Phophi Ramathuba, is currently doing the exact opposite. Despite opposition from the community and health professionals, she has ordered the transfer of a staggering 3,700 patients from an NGO where they are receiving high quality care back onto the public system, which at this moment has little capacity to receive them.

This is a situation reminiscent of Life Esidimeni. Time and money is now being wasted in court proceedings challenging her conduct. People will die.

Organise a bosberaad between health experts, the Treasury and the National Department of Health.

There is mounting evidence that austerity and budget cuts are suffocating health systems. We may not be able to avoid our fiscal crisis, but we can prioritise and plan in a manner that is lawful and in accordance with the Constitution. Budgeting for health lacks transparency, accountability and public engagement. The Treasury urgently needs to develop a better understanding of the need for long-term planning for health.

Freezing essential posts (be they of cleaners or doctors) is not the only way to save money. In fact, it’s a false saving. There are other ways of saving money. For example, SECTION27 and the Treatment Action Campaign-supported publication Spotlight has exposed rampant corruption in the healthcare system, much of it with the tacit or direct support of (now former) premiers, MECs and heads of department. Some of the worst corruption is now the subject of Hawks, Special Investigating Unit and Treasury investigations, but those investigations will not be enough to rebuild trustworthy and principled departments of health in North West, Limpopo, Mpumalanga and the Free State. Corruption and cadre deployment have hollowed out the management capacity of many departments – we need a serious plan to fix them. Yet, while posts are being frozen and people are dying for want of medicines, corruption remains unpunished.

President Ramaphosa, corruption in the health system directly costs lives. Appoint a special tribunal to investigate corrupt officials and tenders. Make it safe for whistle-blowers to step forward. Make sure that the money that is saved goes straight back to hospitals and clinics.

Thuma Mina to fix the health system

In making the above proposals I want to suggest that there is a way. Tap into the “Ramaphoria” of the middle and business classes and ask them to volunteer to make a difference in the lives of the poor.

Get the right people in the room to fix the health system: this must include parts of civil society, key private sector leaders in health, and government departments that are essential to health.

The key indicator as to who should be there is (a) do they have the will? and (b) do they have the ideas, the means and power? Encourage innovation, out-of-the-box thinking and work meaningfully with partners.

Tell people who have a vested interest in the status quo to stay at home. Don’t let them hold progress and action hostage to the lowest common denominator, as happens in institutions like the SA National AIDS Council. We want solutions.

Order this group to come up with strategies to fix a small number of large problems! If we concentrate our efforts, getting results might have a ripple effect. This would also raise morale.

Let’s take the cancer crisis as an example. In the State of the Nation Address you promised to launch “a huge cancer campaign similar to the HIV counselling and testing campaign”.

The minister repeated this promise in his budget speech. This is so necessary. But, if we are about to diagnose tens of thousands of people with cancers, it would wrong if we aren’t able to offer them care and treatment. How are we going to do that without oncologists, with broken radiation machines, hospitals with a shortage of beds and unaffordable drugs?

So, President Ramaphosa ,appeal to private oncologists to sign up for work in public hospitals; appeal to private health bosses to allow public sector patients to be treated in private hospitals. Act on the principles Cabinet has now approved concerning intellectual property to rapidly bring the prices of essential cancer medicines down.

Maybe there are other solutions for the short-term and longer-term changes needed. But only by asking for solutions will they be revealed.

But cancer is by no means our only challenge. A similar plan must be devised to quickly and dramatically reduce the number of babies who are dying or being disabled at birth. Thirteen years ago, a report studying peri-natal death and injury concluded:

The BAD NEWS is that … “one in five deaths could have been clearly avoided”, and inequalities are also highlighted with avoidable deaths being twice as common in rural areas. The same avoidable causes are still being seen in this fifth report as were seen in the first report.

The GOOD NEWS is that these deaths are not complex or expensive to prevent – improving the quality of care during childbirth is a top priority that would also save mothers’ lives and reduce long-term disabilities in children. (2003-2005, Fifth Peri-natal care survey.)

Unfortunately, 10 years later the 2014-2016 report on Saving Babies still records “intra-partum asphyxia as a major preventable cause of death” with 72% of those deaths in mothers with no obstetric conditions. Babies are being deprived of oxygen during birth and dying and being severely disabled. Just as they did 10 years ago. Surely a solution can be found.

These are just two examples of issues on which the health system ought to be capable of making rapid progress. A coalition of the willing may conclude that there are others.

What must animate our approach to the health crisis is the belief that we can fix it. The achievements of our united response to Aids is evidence of that. Remember that in 2008, after years of Aids denialism, there were only a few hundred thousand people on ARVs. Today there are over four million people. This took vision and a concerted effort. The response to Aids didn’t just save lives: it lifted spirits, restored hope, brought in expertise and budgets that reinvigorated parts of the health system closest to the Aids response. Is it not possible to do the same for cancer or mental health? DM

Mark Heywood, Director, SECTION27

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